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Clinical Presentation of Significant Disc Bulge

Patient History

A 21-year-old male patient employed as a daycare teacher, with the leisure activity of golf, was referred to Physical Therapy by a family practitioner who diagnosed the patient with low back pain.

He complains of intermittent right greater than left back pain; right posterior thigh / leg pain/numbness, and less intense left posterior thigh pain/numbness that have been present for 1-2 years. The condition commenced for no apparent reason and has been worsening in intensity and frequency overall.

The patient reports functional disability of inability to bend to tie his shoes, especially in the morning; perform usual cleaning activities at work and home; and playing golf. Initial self-rating on the Oswestry Low Back Disability Index is at 32% (Moderate disability).

The patient has undergone Chiropractic care previously without improvement and is currently taking NSAIDs for pain control. He is in good health, has no bowel/bladder dysfunction, or gait disturbance.

Co-author:
Carol P. Dionne, PT, PhD, OCS, Cert MDT
Assistant Professor, Department Rehabilitative Sciences
University of Oklahoma Health Sciences Center
Oklahoma City, OK

Examination

Observation: The patient presents with poor sitting posture and fair standing posture. Correction of posture had no effect on symptoms. Lumbar lordosis appeared normal, without any obvious lateral shift.

Neurological Testing: There were no apparent deficits in motor, sensory or reflex testing; he had a positive right straight leg raise at 55-degrees and a positive slump test.

Lumbar Movement Loss: There was minimal loss of lumbar flexion in standing with a right deviation from the sagittal plane, minimal loss of lumbar extension in standing, minimal loss in side-gliding to the right; and no loss in side-gliding to the left.

Repeated Movement Testing of Lumbar Spine

In standing:

  • Baseline symptoms: back pain only
  • Flexion in standing: produced right posterior thigh pain, increased with repetition, and remained worse
  • Extension in standing: increased back and right thigh pain, increased with repetition, and remained worse

In recumbent:

  • Baseline symptoms: back pain only
  • Lumbar flexion in supine (knees-to-chest): no effect on symptoms
  • Extension in lying (press-up): produced right thigh pain, peripheralized with repetition, and remained worse

Other Mechanical Tests:

  • Extension in lying with hips offset left: increased right thigh, peripheralized, and remained worse
  • Trunk rotation in flexion to the left: had no effect on the symptoms

The provisional mechanical diagnosis based on history and mechanical testing after the initial visit was irreducible derangement of the intervertebral joint complex in the lower segments of the lumbar spine. Further testing over at least 3 visits was needed to confirm or refute this diagnosis and exhaust all mechanical procedures in attempt to reduce the derangement.

Prior Treatment

The initial treatment chosen was flexion in lying, as this was the only test procedure that did not increase his symptoms and has the potential to expose a symptomatic posterior disc herniation. The patient was instructed to perform flexion in lying 4-6 times per day, not to alter any other activity, and asked to return the next day for reassessment.

Upon the second session, he was unchanged and reassessment of his symptomatic and mechanical response to movement testing was reassessed over that visit and the third session 2 days later.

The results of the tests were as follows:

  • Side-gliding in standing to the right demonstrated production of leg pain, which remained worse with repetition.
  • Lumbar rotation mobilization, in extension to the right, demonstrated production of leg pain, which remained worse with repetition.
  • Lumbar rotation in flexion right had no effect on symptoms.
  • Lumbar traction with the patient in flexion and extension had no effect on his symptoms.

At the conclusion of the second session, the physician was contacted as no change in pain or function had resulted from mechanical testing and there was suspicion of significant irreversible disc pathology. Magnetic resonance imaging (MRI) was suggested based on these concerns.

Images

The patient subsequently was sent for MRI to confirm the clinical presentation. The impression reported by the radiologist was: at the L5-S1 intervertebral segment, a large central extruding disc with moderately advanced acquired stenosis to the central canal. The exiting foramina are patent; disc space is thinned and dehydrated. (Figs. 1, 2)

lumbar sagittal MRI
Figure 1. Sagittal MRI

lumbar axial MRI
Figure 2. Axial MRI

Discussion of Treatment Options and Recommendation

This patient did not centralize, or show any directional preference to repeated movement testing, and therefore was classified as a non-responder likely due to irreversible disc pathology (irreducible derangement). This sort of structured history and physical examination has been shown to reliably and quickly identify those with back and or leg pain emanating from the spine, who are capable of responding and those who will not respond to conservative care. This presents good evidence of the ability for specially trained Physical Therapist to be first in line to manage most activity related spine disorders, as the majority of these patients will respond rapidly and require no further intervention. Those who do not respond are quickly identified and referred on to the appropriate healthcare provider for further diagnostic testing and possibly more aggressive management.

References
1. Aina A, May S, Clare H. The centralization phenomenon of spinal symptoms - a systematic review. Man Ther. Aug;9(3):134-143, 2004.

2. Donelson R, Aprill C, Medcalf R, Grant W. A prospective study of centralization of lumbar and referred pain. A predictor of symptomatic discs and annular competence. Spine. May 15;22(10):1115-22, 1997.

3. Long A. The centralization phenomenon: its usefulness as a predictor of outcome in conservative treatment of chronic low back pain (a pilot study). Spine. 20(23):2513-2521, 1995.

4. Skytte L, May S, Petersen P. Centralization: Its prognostic value in patients with referred symptoms and sciatica. Spine. 30:E293-E299, 2005.

5. Wetzel FT, Donelson R. The role of repeated end-range / pain response assessment in the management of symptomatic lumbar discs. Spine J. 3:146-154, 2003.

6. Razmjou H, Kramer JF, Yamada R. Intertester reliability of the McKenzie evaluation in assessing patients with mechanical low-back pain. J Orthop Sports Phys Ther. Jul;30(7):368-383, 2000.

7. Alexander LA, Hancock E, Agouris I, Smith FW, MacSween A. The response of the nucleus pulposus of the lumbar intervertebral discs to functionally loaded positions. Spine. 32:1508-1512, 2007.

8. Schnebel BE, Simmons JW, Chowning J, Davidson R. A digitizing technique for the study of movement of intradiscal dye in response to flexion and extension of the lumbar spine. Spine. Mar;13(3):309-12, 1988.

9. McKenzie RA, May S. The Lumbar Spine. Mechanical Diagnosis and Therapy. (Vol. 1 and 2). Spinal Publications, Waikanae, New Zealand; 2nd Edition, 2003.

Suggest Treatment

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Outcome

The patient was informed of his imaging results. He was given education regarding the favorable natural resolution of such conditions, and that remaining as active as possible without aggravating his pain is generally recommended. He was instructed in a global conditioning program with emphasis on the core musculature, as many find non-painful, general conditioning exercises helpful.

He was discharged from physical therapy (PT) services and referred to a surgeon for consultation to assist in making an informed decision about his management.

The patient was contacted one-year following discharge from PT. He reported no change in his leg pain/numbness but still maintains his usual work, social and recreational activity. He has been managing his symptoms with Lyrica® for the last 1-year. He has made a decision to proceed with surgery to relieve his symptoms sometime in the next few months.

Case Discussion

The clinical history is an otherwise healthy, 21-year-old young man, who was carrying out no significant physical activity other than that associated with a daycare teacher (perhaps lifting small children) and golfing. There was a very diligent analysis of torso exercise activity to determine those maneuvers which increased his symptoms by peripheralization, or could improve him by centralization. He presents as having only back pain at rest but many physical maneuvers peripheralize the pain to be in the right thigh. Only flexion while lying seemed to not cause an increase in his leg pain. On this basis, noting that was his directional preference, he was instructed to carry out repeated flexion in a lying position. This made no difference. Ultimately, he was sent for an MRI, which demonstrated a significant bulging disc which is read as partially extruding, as well as degenerative changes at L5-S1. This is in the central canal and not disturbing the foramina. He is now being set up for surgery.

This is an unusual case, first of all because the problem presents in an individual so young. Also, in the majority of cases, when being analyzed by competent therapists in mechanical diagnosis (McKenzie), true centralization occurs and gradually the symptoms diminish. The fact that flexion in lying does not increase his symptoms is also surprising in that, as noted by the studies quoted in the reference by Alexander, et al, noting posterior protrusion of the nucleus on flexion, which confirmed the earlier studies of Schnabel, et al, using interdiscal dye, flexion should have made his symptoms worse, as did every other torso maneuver. This suggests that the nuclear material which the MRI demonstrates with the high intensity zone seen on the sagittal view, is not movable.

Before proceeding with surgery, I believe there are two more hoops for the patient to jump through. The intermittent character of his pain suggests that it is secondary to chemical irritation rather than mechanical irritation. On that basis, trying to change the metabolic environment of the disc is justified. Even though flexion and extension maneuvers while standing (loads) did not reduce his symptoms, a more vigorous attempt to create metabolic exchange in the disc is justified. In my experience, this can be done by flexion and extension activity of the lumbar spine with the pelvis fixed and significant resistance in both concentric and eccentric motions. In my experience, this has been successful in a significant number of patients using MedX equipment. I am unaware, however, of any literature report for this specific circumstance. Even if spontaneous disc extrusion occurs in the central canal, it is unlikely to cause significant neurologic symptoms, and the nuclear material, once extruded into the central canal, will rapidly resolve. Occasionally, however, depending on how much nuclear material is available for extrusion, a significant increase in neurologic symptoms will occur. This has apparently not occurred so far in that the symptoms appear to be in the back only.

Another reasonable preoperative maneuver would be a one-time only epidural injection in the central canal area at L5-S1 under fluoroscopic guidance. As noted above, this is apparently a local metabolic phenomenon, creating chemical irritation to the annulus, magnified to the nerve roots with appropriate increase in protrusion (peripheralization of pain). Even through the track record for epidural injections is somewhat unpredictable, in experienced hands, it is quite safe and nondestructive, especially in the one-time only occasion.

There is some justification to try to avoid surgical care. Central discs have a less successful track record than lateral discs, especially when there is a large rent in the annulus. On the other hand, modern approaches with minimally invasive methodology include less muscle and soft tissue destruction than in the earlier days.

Aside from the therapeutics discussed above, there is an interesting side note for contemplation. As noted in the history, there was not an unusually physically demanding lifestyle up to this time. Why should the disc degenerate and have a nucleus in extruding position? A very excellent survey of the etiology of disc degeneration was published recently in the Spine Journal. (1) This study points out the changing concepts of etiology noting that physical demands in life have very little to do with disc degeneration. This information was gleaned from studies of twins in several countries. The study pointed out with MRI confirmation that the degenerative status of the spine was pretty much the same regardless of the physical demands in life of the twin pairs. Much more of the etiology of degeneration is based on genetics than on lifestyle. This observation therefore challenges the concept of workplace injury as the source of disc deterioration.

It certainly would be interesting to get a follow-up on this clinical story one-year later. Because of the age group, it is quite unusual, but that's what keeps clinical practice so interesting.

Reference
1. Battie, NC, Videman, T, Kaprio, J, et al, The Twin Spine Study: Contributions to a Changing View of Disc Degeneration. Spine Journal, Volume IX, 2009, 47-59.

Author's Response

The comments regarding genetic predisposition to disc degeneration are very interesting. It seems I was given the opportunity to work with this young man, because, 2 months previous, I worked with his father with similar problems, who responded quite well to mechanical therapy. If I remember correctly, the father's MRI demonstrated multilevel degenerative disc disease.

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